Blood Transfusion Consent Form
Patient Name:
Date of Birth:
Medical Record Number:
Purpose and Procedure
Description of blood transfusion procedure:
Risks and Benefits Discussion
Risks explained to patient:
Benefits explained to patient:
Alternatives discussed:
Questions asked and answered:
Consent
I hereby consent to the transfusion of blood and/or blood products as recommended by my healthcare provider.
Patient / Legal Representative Signature:
Date:
Healthcare Provider Signature:
Date: